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RECEIPT MODEL (Official Journal of December 7, 2003; Official Tax
Bulletin 5 B-1-04)

For all gifts (payments, write-offs of income or f ees incurred by the association) that you wish to
consider in calculating your tax reduction (regardless of the beneficiary agency and the amount
of the donation), you must attach your receipts in accordance with the official model (see below),
which states the amount paid, to your tax return. Failing this, unexplained amounts will be not
considered. For donations to campaigns and political parties, see the next page.

However, the organization is not required to list all information about the model’s “beneficiary” on
its receipt insomuch as certain categories do not apply.
Attention: If you sign your 2003 tax return online, keep the receipt issued by the organization.
You must produce it at the request of the authorities. To receive a tax reduction, you must list
the name of each beneficiary and the amount of each payment on your tax return.

N° 11580*02
Charity Receipt (Articles 200 and 238 bis of the General Tax Code)
Payment Beneficiary Name or Company Name: ……………………………………………………………………………………………………………………………………………………………………………… Address: ……………………………………………………………………………………………………………………………………………………………………………… N° ……………………………………………………………………………………………………………………………………………………………………………… Street ……………………………………………………………………………………………………………………………………………………………………………… ZIP Code Municipality Purpose: ……………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………… Check the appropriate box (1): Charity or General Interest Organization Business Foundation Public Interest Organization or Foundation recognized by a decree dated……………………….. , published in the Officia l Journal of …………………………………………………………………………………………………………………………………………………………………………….. . Museum of France Cultural or Charity Organization authorized to receive gifts and legacies through a decision dated …………………. issued by the pre fect. of ……………………………………………………………………………………………………………………………………………………………………………… Private, accredited, non-profit higher or artistic education establishment through a decision dated…………………. ……………………………………………………………………………………………………………………………………………………………………………… Association providing assistance, food or medical care free of charge to people in need or assisting with housing. Agencies having the exclusive task of participating financially in the creation of businesses. Associations located in the department of Moselle, Bas-Rhin or Haut-Rhin whose mission has public interest status through a prefectoral decree dated ………………………………………………………………………………………………………………….. Public establishment for recognized religions in Alsace-Moselle. Accredited scientific or technical research company or agency (2) Agency whose main activity is to organize festivals (2)

Donor Name: ……………………………………………………………………………………………………………………………………………………………………………… Address: ………………………………………………………………………………………………………………………………………………………………………………
ZIP Code ……………………. Municipality ……………………………………………………………………………………………………………………. The beneficiary acknowledges to have received payments that qualify for a tax reduction in the amount of : Amount in Words: ……………………………………………………………………………………………….. ……………………………………….. Date of Payment: ………………………………………………………………………………………………………………………………………………….. Payment Method: Check or Wire Number, Date and Signature Other (3) (1) only indicate information about the agency (2) gifts made by companies (3) in particular: write-offs of income or products; expenses incurred by the beneficiaries for which reimbursement is not requ ested